Abstract
Psychological distress associated with surgery is an emerging issue. The study was conducted to assess the impact of structured patient education viz-a-viz routine patient education on anxiety and depression levels in patients undergoing elective chest surgery. It is a prospective, double-blind randomized study, conducted from February 2019 to February 2020 at a tertiary care center in India, on patients who underwent elective chest surgeries. A total of 300 patients were randomized using a computer-generated randomization sequence, into 2 equal groups (150 subjects each). Study group included patients who underwent structured patient education (Group A), whereas control group included patients who underwent routine patient education (Group B). The 2 groups were compared for anxiety and depression levels at admission as well as discharge using Hospital Anxiety and Depression Scale. Also, at the time of discharge, the groups were compared for the effectiveness of patient education using a validated Questionnaire B. In comparison to routine education, patients receiving structured education showed significantly lesser scores for anxiety and depression at discharge (P < .001). Also, structured patient education proved to be effective in comparison to the routine education in educating the patients in all parameters as determined by the Questionnaire B (P < .05). It can be concluded that structured educational intervention is strongly recommended in patients undergoing chest surgery which can help alleviate perioperative anxiety and depression. Such intervention helps patient get an understanding of the surgical procedure and assist them in facing the condition in a better way.
Keywords: structured education, anxiety, depression, chest surgery
Introduction
Conventionally, thoracic surgical procedures were considered a potential to cause significant morbidity and mortality. The fear of such surgery and undue psychological stress predisposes the patient and relatives to a lot of anxiety and depression. Lack of proper communication, fear of postoperative pain and whether they will return to normal life after lung removal along with its financial implications, adds to the problem. It was reported that nearly 60% of patients who opt for elective surgery are known to experience anxiety (1).
Even though, anxiety is a quite natural response, excessive psychological stress/distress reduces the adjustment of patients in the hospitals and is co-related with adverse outcomes and unexpected results (2). Therefore, addressing patient's psychological needs by perioperative education and counselling is as essential as clinical needs. Patient education, if done in a planned, organized, progressive, and logical manner can help alleviate a lot of psychological distress in patients in the clinical settings (3). It is known to be an essential tool to provide patients with information concerning their health condition, treatment, and recovery (4). Preoperative education includes information regarding the procedure, hospitalization, financial counselling, postoperative pain, recovery, and long-term functional outcome (5). In addition, patient educational program should be patient-centered, which means that the information should be patient specific and tailored towards their need (6).
In the recent times, with various pioneering advancements in the patient selection, operative methods and postoperative care, the outcomes of thoracic surgical procedures have remarkably improved. However, there were very little efforts to address the psychological aspect of the patients undergoing chest surgery. This study aims to fill this gap by studying the impact of structured patient education on anxiety and depression levels in patients undergoing elective chest surgery by using Hospital Anxiety and Depression Scale (HADS).
Materials and Methods
This prospective, double-blind randomized study was conducted from February 2019 to February 2020 at a tertiary care center in India. All patients admitted for elective chest surgery with age >18 years were included in the study. Age <18 years, emergency surgery, patients with psychiatric diseases, unconscious or unwilling to consent were excluded from the study. Ethical clearance was obtained from the Institutional Ethical Committee of the hospital.
A total of 300 patients were included in the study and were randomized into 2 groups of 150 subjects each using a computer-generated randomization sequence. Study group included patients who underwent structured patient education (Group A), whereas control group included patients who underwent routine patient education (Group B). Representation of study methodology is illustrated in Figure 1.
Figure 1.
Flow chart of study methodology.
Routine Patient Education
Routinely, patients were educated at various point of care—at OPD (primarily), at the time of admission and at the time of discharge. The mode of providing the education was verbal and informal. Total time of interaction was usually not more than 10-15 min. No checklist was used and uniformity was not maintained. Therefore, possibility of skipping an essential information to the patient was high.
Structured Patient Education
In addition to the routine patient education, formal and structured patient education session was conducted at the time of admission, by a team comprising of a resident Doctor, nurse coordinator and Hospital Administrator. Structured patient education was given to the patients verbally as well as in the written format through a brochure and the patient was asked to repeat what he understood. At the end of the session the brochure was handed over to the patient and all queries of the patient were resolved by the team. In order to ensure that patients receive uniform information, a checklist was also used.
Brochure—A brochure was designed after analyzing the data for the routine patient education so as to be specific about the information patient perceives as important. It included information highlighting the need and importance of physiotherapy as well as nutrition/diet plan. The emergency contact numbers were also mentioned along with the website address for the testimonials and updates (Figure 2).
Check list—With the help of a check list, it was ensured that no information is being skipped so as to maintain uniformity while imparting patient education to all the patients (Figure 3).
Figure 2.
Patient brochure describing essential components of structured patient education.
Figure 3.
Checklist.
Two questionnaires (Figure 4), i.e., Questionnaire-A: to measure anxiety and depression levels; and Questionnaire-B: to measure the effectiveness of the patient education were used.
Questionnaire-A (Q-A): HADS was used to measure the levels of anxiety and depression (7) (Figure 4: Q-A) which is an already validated scale developed by Zigmond AS, Snaith RP. It has total 14 questions—7 scoring anxiety and 7 scoring depression. The possible range of score is from 0 to 21. A score of ≤7 is normal, score of 8-10 indicates borderline abnormal, while score ≥11 is abnormal.
Questionnaire-B (Q-B): This was designed with 7 parameters to assess the effectiveness of patient education (Figure 4: Q-B). A standardized Likert scale (0-3 points) was used for scoring. The same was validated group of domain experts before administration.
Figure 4.
Questionnaire A—Hospital Anxiety and Depression Scale (HADS) & Questionnaire B—to assess the effectiveness of patient education.
Statistical Analysis
Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± SD and median. Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected then non-parametric test was used. Quantitative variables were compared using Mann–Whitney test (as the data sets were not normally distributed) between the 2 groups. A P value of <.05 was considered statistically significant. The data was entered in MS EXCEL spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.
Results
Demographic Characteristics
Both the groups were comparable in terms of age, gender ratio, educational status, marital status, and disease-related characteristics. Only 10.6% patients in the total study group have visited the hospital for the first time and thus majority of the patients had prior knowledge of the disease in both the groups. It was also seen that majority of the patients had a history of self/family member undergoing a major surgery. The baseline socio-demographic profile and disease characteristics have been shown in Table 1.
Table 1.
Socio-Demographic Profile and Disease Characteristics.
| Parameters | Group A (n = 150) (Structured education) | Group B (n = 150) (Routine education) | P-value |
|---|---|---|---|
| Age in years (Mean ± SD) | 47.2 ± 15.8 | 44.2 ± 15.3 | .092 |
| Gender (n, %) | |||
| Males | 105 (70%) | 110 (73.3%) | .522 |
| Females | 45 (30%) | 40 (26.6%) | |
| Education (n, %) | |||
| 8-10 class | 4 (2.6%) | 3 (2%) | .123 |
| 11-12 class | 16 (10.6%) | 24 (16%) | |
| Graduates | 71 (47.3%) | 82 (54.6%) | |
| Post-graduates | 59 (39.3 27.3%) | 41 (27.3%) | |
| Married (n, %) | 129 (86%) | 129 (77.3%) | .052 |
| Joint family (n, %) | 100 (66.6%) | 85 (56.6%) | .096 |
| Disease-related characteristics | |||
| First visit to doctor—Yes | 4 (2.6%) | 12 (8%) | .069 |
| Consultation from another doctor for the same ailment before—Yes | 135 (90%) | 128 (85.3%) | .292 |
| Prior knowledge of the disease—Yes | 115 (76.7%) | 107 (71.3%) | .357 |
| History of self/family member undergoing major surgery—yes | 108 (72%) | 99 (66%) | .318 |
Comparison of Anxiety Scores
At admission, majority of patients who received structured education (Group A) (68%) and routine education (Group B) (76.6%) had borderline anxiety scores, whereas 10% patients of Group A and 22% patients of Group B had abnormal anxiety scores. Overall, there was no difference in the preoperative anxiety scores between the 2 groups (P = .19).
At discharge, 84.6% patients who received structured education (Group A) had achieved normal anxiety scores, whereas in Group B it was seen in only 22% of patients. Fifty eight percent patients in Group B continued to have borderline anxiety scores (Table 2).
Table 2.
Comparison of Anxiety Scores Between Groups.
| Anxiety score | Group | P-value | |
|---|---|---|---|
| Group A (n = 150) (Structured education) |
Group B (n = 150) (Routine education) |
||
| At admission (n, %) | |||
| Normal (≤7) | 33 (22%) | 2 (1.3%) | .19 |
| Borderline abnormal (8-10) | 102 (68%) | 115 (76.6%) | |
| Abnormal ( ≥ 11) | 15 (10%) | 33 (22%) | |
| Mean ± SD | 9.0 ± 1.9 | 8.7 ± 1.5 | |
| At discharge (n, %) | |||
| Normal (≤7) | 127 (84.6%) | 33 (22%) | <.001 |
| Borderline abnormal (8-10) | 23 (15.3%) | 87 (58%) | |
| Abnormal ( ≥ 11) | 0 (0%) | 30 (20%) | |
| Mean ± SD | 2.7 ± 2.6 | 5.4 ± 2.4 | |
Comparison of Depression Scores
At admission, majority of patients in Group A (46.6%) and Group B (50.6%) had borderline depression scores, whereas 27.4% patients who received structured education and 36.6% patients receiving routine education had abnormal depression scores. Overall, there was no difference in the preoperative depression scores between the 2 groups (P = .21).
At discharge, 71.3% patients in Group A had achieved normal depression scores, whereas in Group B it was seen in only 42% of patients. In addition, 44.6% and 13.3% patients in Group B continued to have borderline abnormal and abnormal depression scores respectively (Table 3).
Table 3.
Comparison of Depression Scores Between Groups.
| Depression score | Group | P-value | |
|---|---|---|---|
| Group A (n = 150) (Structured education) | Group B (n = 150) (Routine education) | ||
| At admission (n, %) | |||
| Normal (≤7) | 39 (26%) | 19 (12.6%) | |
| Borderline abnormal (8-10) | 70 (46.6%) | 76 (50.6%) | |
| Abnormal ( ≥ 11) | 41 (27.4%) | 55 (36.6%) | |
| Mean ± SD | 8.8 ± 1.7 | 9.1 ± 2.4 | .21 |
| At discharge (n, %) | |||
| Normal (≤7) | 107 (71.3%) | 63 (42%) | |
| Borderline abnormal (8-10) | 43 (28.6%) | 67 (44.6%) | |
| Abnormal ( ≥ 11) | 0 (0%) | 20 (13.3%) | |
| Mean ± SD | 2.1 ± 1.3 | 4.9 ± 1.9 | <.001 |
Comparison of Patient Education Effectiveness Score
Structured patient education (Group A) proved to be effective as compared to routine education (Group B) educating the patient in all parameters which was reflected in their mean scores as determined by the Questionnaire B at the time of discharge. The individual parameters and their results are mentioned in Table 4.
Table 4.
Patient Education Effectiveness Score.
| Parameters | Group A (Mean ± SD) (Structured) |
Group B (Mean ± SD) (Routine) |
P-value |
|---|---|---|---|
| Communication | 11.3 ± 1.3 | 10.9 ± 1.9 | .03 |
| Disease information | 10.8 ± 0 | 8.1 ± 1.2 | <.0001 |
| Information related to procedure | 11.8 ± 0.3 | 10.6 ± 1.3 | <.001 |
| Information related to physiotherapy | 10.7 ± 1.2 | 10.3 ± 1.5 | .01 |
| Information related to nutrition/diet plan | 10.5 ± 1.1 | 10.2 ± 1.3 | .03 |
| Financial counselling and hospital stay | 10.9 ± 0.9 | 7.1 ± 1.5 | <.0001 |
| Follow-up advise | 11.3 ± 0.1 | 9.5 ± 1.2 | <.0001 |
Discussion
Undergoing surgery is physically and psychologically stressful for patients and their families. A structured patient education rather than the routine education may help better, to reduce the psychological stress in such patients.
In our study, the patients undergoing elective chest surgery were predominantly males in their forties. Different studies conducted on patient education to reduce psychological stress during surgery reported varied ages, depending upon the type of surgery. For example, studies conducted on patients undergoing heart surgeries were having the mean age of 60-63 years with majority being males (69%-72%) (4,8). Most of the patients in our study were graduates and we made sure to select only those patients who could comprehend the information. Therefore, educating patients was not a limitation. A structured information was an appropriate way of letting the patients know about the various aspects of the disease to calm them down in this difficult phase of their life. Our data showed that both the groups were similar in terms of socio-demographic characteristics. Majority of the patients in both the groups were mainly referred, had beforehand consultation from another doctor for the same ailment along with prior knowledge of the disease. This was mainly because ours is a tertiary care center and caters to all the referral patients for chest surgery nationally as well as internationally.
Previous similar studies showed a significant difference between control group (without education) and experimental group (with educational interventions) in relation to preoperative anxiety and depression levels (P < .05) (9,10). Study conducted by Kalliyath et al demonstrated that a planned preoperative education including a handout with details can have a significant impact on reducing preoperative anxiety (11). In contrast, another study demonstrated that there was no benefit to be gained by preoperative education in cardiac surgery (which was one day of education by members of the multidisciplinary team) (4). These contrasting results could be explained by the fact that heart surgeries are by far the most complicated and carry the burden of causing the highest anxiety in the patients; despite providing vast amount of information to the patients and the relatives. Our study was unique because of 2 reasons. First, it is first study of its kind from India which has prospectively evaluated the effect of structured patient education in thoracic surgical patients and second, the evaluation was compared at 2 levels, that is, preoperatively as well as postoperatively. Our study found that with structured patient education, the anxiety and depression levels were significantly decreased at discharge (postoperative) (P < .05) as compared to the routine education. On further questioning in control group, the major reason for persistence of the anxiety at the time of discharge was improper follow-up advice and lack of information regarding proper dietary and physiotherapy plan. However, lack of knowledge with respect to the ability as well as the time required to return to normal activity were the major factors for persistence of depression.
The preoperative anxiety is multifactorial and can be influenced by the educational status of the patient, level of understanding of ground reality of the disease, economic status, level of trust on the surgical team and the hospital services. Since we included only elective thoracic surgery cases, we were able to alleviate anxiety and depression by providing structured information to the patient. As mentioned earlier, apart from structured information, this may also be affected by various other factors. A similar study by Ortiz et al (12) concluded that patient education handouts improved patient satisfaction regarding their knowledge of the perioperative process but did not reduce anxiety related to surgery.
This study also, revealed significant rise in the effectiveness of the patient undergoing structured education related to all the parameters as per Q-B. Our structured patient education helped the patients to understand the information in a better manner as all their queries were answered on one-to-one basis by the healthcare professionals. It allowed the patients to know in detail about the disease as well as surgery and its outcome. The patients were thoroughly educated about the need and importance of physiotherapy and were also motivated to do the exercises in presence of the physiotherapist. Also, patients were educated about the importance of nutrition by the dietician and proper customized diet plan was handed over to each patient. The follow-up treatment and care of patients were better managed. Through the brochure as well as the check list, the uniformity was maintained while educating the patients, without missing any important information. Patients were thoroughly informed about the health insurance details, length of stay, and the finances as per the room categories available. All the important contact numbers were mentioned on the brochure along with the website details.
This is the largest randomized study from India which has evaluated the role of structured patient education in thoracic surgical patients. However, this study has a limitation, that is, only subjective outcomes were assessed and the objective outcomes such as related to pain, type of disease, chest drain duration, complications, and so n were not assessed. Encouraged by the results of this study, we are planning our next study taking all these parameters into consideration. So, we would recommend that patient education must be a continuous effort at various intervals aimed at both subjective as well as objective outcomes. A single day of education without an associated program of support may be inadequate. It is imperative to provide written material as well as visual aids for patients to consult after the education sessions. Information needs to be in a language and format which is easy for the patients and relatives to understand. More studies need to be conducted and the results incorporated in overall patient management plans to have a better psychological outcome after the chest surgeries.
Conclusion
It can be concluded that perioperative structured educational intervention can help alleviate anxiety and depression in patients undergoing elective chest surgery. Such intervention helps patient get an understanding of the surgical procedure and assists them in facing the condition in a better way. A good communication between the healthcare professionals and patients during admission and at discharge, to cover all required information related to their disease, surgery and its outcome, physiotherapy, diet/nutrition, financial counselling, medical insurance as well as follow-up advice, may play a positive role in battling the psychological distress of the patients. Our study strongly recommends the replacement of ongoing practice of “informal routine” education with the “structured” one for alleviating the patients’ anxiety and depression in a better way.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Tilotma Jamwal https://orcid.org/0000-0002-9999-4978
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